Making a Statement: Positions of Professional Medical Organizations Towards Gender-Affirming Care.

OBJECTIVE: Despite politically charged media coverage and legislation surrounding gender affirming care (GAC), many organizations have released position statements to provide scientifically backed clinical practice standards, combat misinformation, and inform medicolegal policies. The purpose of this study is to objectively assess the availability and the content of the official position statements of relevant medical professional organizations regarding GAC. SUMMARY BACKGROUND DATA: A list of U.S. medical professional organizations with likely involvement in GAC based on medical or surgical specialties was compiled. METHODS: For included organizations, we evaluated the availability, content, and publication year of positions on GAC through October 2023. When available, formal positions were categorized as supportive or unsupportive. RESULTS: A total of 314 professional medical organizations were screened for our study based on specialty, relevance to GAC, and issuance of patient guidelines or position statements. Inclusion criteria were met by 55 organizations. Most organizations (35, 63.6%) had formal position statements on GAC. Support for GAC was described in 97.1% (n=34). Further, 94.2% (n=33) of available statements explicitly addressed GAC in individuals less than 18 years old and were largely supportive (96.9%, n=32). CONCLUSIONS: This cross-sectional analysis demonstrates that a majority of multidisciplinary professional medical organizations with relevance to GAC have issued formal position statements on the topic. Available positions were overwhelmingly supportive of individualized access to gender-affirming therapies in adult and adolescent populations. However, silence from some organizations continues to represent a modifiable disparity in the provision of GAC.

Phantom sensation in genital gender-affirming surgery: a narrative review.

PURPOSE OF REVIEW: To review findings related to phantom genital sensation, emphasizing phantom sensation in the transgender and gender diverse (TGD) population. We discuss prevalence, presentation and potential implications for sensory outcomes in genital gender-affirming surgery. RECENT FINDINGS: There is a high prevalence of phantom genital sensations in the TGD population. The prevalence varies by body part, approaching 50% in the most frequently reported transgender phantom - the phantom penis. Unlike genital phantoms that occur after trauma or surgery which are often painful, transgender phantoms are typically neutral and often erogenous in experience. Phantom sensation in the TGD population can be an affirming experience and important part of sexual well being and embodiment. SUMMARY: Recent studies have begun to characterize the prevalence and presentations of phantom genital sensations in TGD people, informing our evolving understanding of the sensory experiences of the transgender and gender diverse population. Targeting integration of these centrally-mediated phantom genital sensations with the peripherally generated sensation from genital stimulation may represent one potential avenue to improve sensation and embodiment following genital gender-affirming surgical procedures. Additionally, emerging techniques in modern peripheral nerve surgery targeting phantom pain may offer potential treatment options for painful phantom sensation seen after cases of genital surgery or trauma.

Factors Affecting the Choice to Forgo Nipple Grafts in Gender-Affirming Chest Surgery.

INTRODUCTION: Some patients pursuing gender-affirming mastectomy prefer to forgo autologous nipple and areolar reconstruction, instead choosing a "no nipple" option. The objective of this study is to evaluate the motives and influences contributing to this decision. METHODS: A retrospective survey-based study of patients undergoing gender-affirming mastectomy over a 4.6-year period was conducted. All patients were offered nipple and areolar reconstruction. A survey was distributed to those who elected to forgo nipple and areolar reconstruction exploring the factors influencing that choice and postoperative satisfaction. RESULTS: Five hundred thirty-six patients underwent gender-affirming mastectomy and 13% chose to forgo nipple and areolar reconstruction. The survey response rate was 72%. Most respondents identified as nonbinary (48%) or transmasculine (42%). Body image, defined in the context of this study as an improvement in body image satisfaction due to achievement of a more gender-congruent appearance, was the most highly cited and most heavily weighted decision-making factor. Concerns about nipple graft outcomes were frequently cited as important but carried less weight. There were no differences between transmasculine and nonbinary patients in terms of motivations for choosing this surgical option. Fifty-eight percent of respondents pursued or planned to pursue chest tattoos, whereas 42% preferred no further chest modifications. Patient satisfaction was high postoperatively (98%), and 82% of respondents would choose to forgo nipple and areolar reconstruction again even if surgical outcomes of free nipple grafts were improved. CONCLUSIONS: Gender-affirming mastectomy without nipple and areolar reconstruction was requested by 13% of patients presenting for gender-affirming chest surgery over the study period and had high postoperative satisfaction among patients who chose this option. This modification of gender-affirming mastectomy is a variation that surgical teams should be aware of. Many reasons to forgo nipple preservation were cited, most of which related to body image. Secondary factors were easier recovery and/or concern about outcomes of free nipple grafts. Many patients wished information about this surgical option was more widely available.

How many nerve fibers innervate the human glans clitoris: a histomorphometric evaluation of the dorsal nerve of the clitoris.

INTRODUCTION: It is frequently quoted in mainstream media that the clitoris has "8000 nerve endings." However, no study has yet quantified the number of nerve fibers (axons) innervating the human clitoris. The dorsal nerves of the clitoris (DNCs) are the primary source of sensation and somatic clitoral innervation. Therefore, reporting the number of axons in the DNCs is an important step in our understanding of clitoral innervation and sexual response with implications for many fields of medical practice. The purpose of this study is to quantify the mean number of axons in the human DNCs and to report the approximate mean number of nerve fibers that innervate the human glans clitoris. METHODS: DNC samples were obtained from 7 transmasculine patients undergoing gender-affirming phalloplasty surgery. At the time of nerve coaptation, a small excess of the DNC (5 mm) was collected for analysis at the proximal level of the clitoral body, just distal of the emergence of the DNCs from underneath the pubic symphysis. Samples were placed into 3% glutaraldehyde fixative, postfixed in 1% osmium tetroxide, and serially dehydrated in ethanol and toluene. Samples were then embedded in araldite, sectioned on an ultramicrotome into 1-µm cross sections, and counterstained with 1% toluidine blue. Histomorphometric evaluation was performed at 1000x magnification with a Leitz Laborlux S microscope and image analysis software (Clemex Vision Professional) to obtain an axon counts. Descriptive statistics were performed to yield a mean and standard deviation of the number of axons in the DNCs. Assuming anatomic symmetry between bilateral DNCs, mean total number of somatic nerve fibers innervating the human glans clitoris was obtained by doubling the mean count of the DNCs. RESULTS: Seven sample DNCs were collected. Of those, 5 were analyzed as 2 did not have sufficient nerve tissue present. The mean number of nerve fibers in the human DNCs was 5140 (SD = 218.4). The mean number of myelinated nerve fibers innervating the human clitoris was 10,281 (SD = 436.8). CONCLUSION: This study is the first to report the number of axons in the human DNC, at a mean 5140. Given the bilateral nature of clitoral innervation and symmetry of anatomic structures, the approximate mean number of myelinated axons that innervate the human glans clitoris is 10,280. When the uncaptured unmyelinated fibers and contributions from the cavernosal innervation are accounted for, it is clear that far Moree than 8000 axons innervate the human clitoris.

Comprehensive Reconstructive Care for Patients of All Gender Identities After Cancer of the Breast.

ABSTRACT: Breast cancer can affect anyone; therefore, it affects people of all gender identities. Reconstructive options after breast cancer must then address the needs of all people. Our institution is unique in its provision of both high-level comprehensive breast and gender affirmation care. In our practice, patients have expressed gender diverse identities during their breast cancer reconstructive journey. In these cases, goals have deviated from traditional breast restoration, gravitating toward gender-affirming mastectomy, or results often seen with "top surgery." We present a framework for the administration of breast cancer care and discussions of reconstruction from a lens of gender inclusivity. Breast cancer is a diagnosis that has been gendered, resulting in the erasure and exclusion of reconstructive needs for people affected by breast cancer that are not cisgender women. This is illustrated through the case of a nonbinary individual seen in breast cancer clinic for multifocal ductal carcinoma in situ. Our standard review of options of "going flat," implant-based reconstruction, and autologous reconstruction led to initial confusion given their early exploration of gender identity co-occurring with a new diagnosis of breast cancer. These scenarios can be challenging when viewed solely from the perspective of a breast reconstructive surgeon or a gender-affirming surgeon alone. Both perspectives are often needed. Our gender-affirming and breast reconstructive teams have discussed methods to identify patients who require more robust discussion of gender identity and reconstructive options in the setting of breast cancer, such as chest masculinization. By adding gender-affirming surgeons to the list of providers available to counsel breast cancer patients, we may be able to better provide early education on all reconstructive options and appropriately address the needs of transgender and gender diverse people affected by breast cancer.

Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery.

BACKGROUND: Despite high rates of online misinformation, transgender and gender diverse (TGD) patients frequently utilize online resources to identify suitable providers of gender-affirming surgical care. AIM: The objective of this study was to analyze the webpages of United States academic plastic surgery programs for the types of gender-affirming surgery (GAS) procedures offered and to determine how this correlates with the presence of an institutional transgender health program and geographic region in order to identify potential gaps for improvement. METHODS: Online institutional webpages of 82 accredited academic plastic surgery programs were analyzed for the presence of the following: GAS services, specification of type of GAS by facial, chest, body and genital surgery, and presence of a concomitant institutional transgender health program. This data was analyzed for correlations with geographic region and assessed for any significant associations. OUTCOMES: Frequencies of GAS services, specification of the type of GAS by facial, chest, body and genital surgery, presence of a concomitant institutional transgender health program, and statistical correlations between these items are the primary outcomes. RESULTS: Overall, 43 of 82 (52%) academic institutions offered GAS. Whether an institution offered GAS varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .329). Whether institutions that offer GAS specified which anatomic category of GAS procedures were offered varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .235). CLINICAL IMPLICATIONS: This identifies gaps for improved transparency in the practice of communication around GAS for both physicians and academic medical institutions. STRENGTHS & LIMITATIONS: This is the first study analyzing the quality, content, and accessibility of online information pertaining to GAS in academic institutions. The primary limitation of this study is the nature and accuracy of online information, as current data may be outdated and not reflect actuality. CONCLUSION: Based on our analysis of online information, many gaps currently exist in information pertaining to GAS in academic settings, and with a clear and expanding need, increased representation and online availability of information regarding all GAS procedure types, as well as coordination with comprehensive transgender healthcare programs, is ideal. Aryanpour Z, Nguyen CT, Blunck CK, et al., Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery. J Sex Med 2022;19:846-851.

Robotic Peritoneal Flap vs. Perineal Penile Inversion Techniques for Gender-Affirming Vaginoplasty.

PURPOSE OF REVIEW: To discuss perineal and robotic approaches to gender-affirming vaginoplasty. RECENT FINDINGS: The Davydov peritoneal vaginoplasty has its origins in neovaginal reconstruction for vaginal agenesis. It has been adapted as a robotic-assisted laparoscopic procedure and provides an alternative to perineal canal dissection in gender-affirming vaginoplasty. Both techniques represent variations of penile inversion vaginoplasty with successful outcomes and overall low rates of major complications reported in the literature. However, there are differing advantages and considerations to each approach. A perineal approach has been the gold standard to gender-affirming vaginoplasty for many decades. Robotic peritoneal gender-affirming vaginoplasty (RPGAV) is an emerging alternative, with potential advantages including less reliance on extragenital skin grafts in individuals with minimal genital tissue, especially among patients presenting with pubertal suppression, and safer dissection in revision vaginoplasty for stenosis of the proximal neovaginal canal. Additional risks of RPGAV include those associated with robotic abdominal surgeries.

Complete Foot Drop With Normal Electrodiagnostic Studies: Sunderland "Zero" Ischemic Conduction Block of the Common Peroneal Nerve.

ABSTRACT: Common peroneal neuropathy is a peripheral neuropathy of multifactorial etiology often left undiagnosed until foot drop manifests and electrodiagnostic abnormalities are detected. However, reliance on such striking symptoms and electrodiagnostic findings for diagnosis stands in contrast to other commonly treated neuropathies, such as carpal tunnel and cubital tunnel syndrome. Poor recognition of common peroneal neuropathy without foot drop or the presence of foot drop with normal electrodiagnostic studies thus often results in delayed or no surgical treatment. Our cases document 2 patients presenting with complete foot drop who had immediate resolution after decompression. The first patient presented with normal electrodiagnostic studies representing an isolated Sunderland Zero nerve ischemia. The second patient presented with severe electrodiagnostic studies but also had an immediate improvement in their foot drop representing a Sunderland VI mixed nerve injury with a significant contribution from an ongoing Sunderland Zero ischemic conduction block. In support of recent case series, these patients demonstrate that common peroneal neuropathy can present across a broad diagnostic spectrum of sensory and motor symptoms, including with normal electrodiagnostic studies. Four clinical subtypes of common peroneal neuropathy are presented, and surgical decompression may thus be indicated for these patients that lack the more conventional symptoms of common peroneal neuropathy.

Partial Flap Loss in Gender Affirming Phalloplasty.

BACKGROUND: Flaps used in phalloplasty are larger than described for other indications, with a design that is tubularized up to two times. While the incidence of partial flap loss (PFL) is well described, current literature lacks granularity comparing donor sites and techniques with minimal discussion of etiology and management. The purpose of this study was to review our experience with PFL in phalloplasty. METHODS: This was a retrospective cohort study of patients who underwent phalloplasty by a single surgeon at a single institution between 2016 and 2020. PFL was defined as any patient requiring sharp excision of necrotic tissue and reconstruction. Patient variables (demographics, body mass index, American Society of Anesthesiologists physical status classification, comorbidities), flap variables (donor site, design, dimensions, perforator number) and intraoperative variables (use of vasopressors, intraoperative fluid volume) were collected. RESULTS: Of 76 phalloplasties, 6 patients suffered PFL (7.9%). 5/6 patients were radial forearm free flap tube-within-tube (TWT) and 1/5 patients were pedicled anterolateral thigh TWT. 4/6 cases involved the shaft only and were treated with excision ± Integra and full-thickness skin grafting. 2 cases of PFL involved the urethral extension requiring excision of the necrotic segment. CONCLUSION: PFL occurred in 7.9% of cases and was solely found in the TWT cohort. The majority of cases involved the shaft, sparing the urethral segment. Cases in the acute postoperative period appeared to be related to macrovascular venous congestion, while cases in the subacute period appeared to be due to microvascular arterial ischemia.

Canadian Trends in Carpal Tunnel Surgery.

PURPOSE: Treatment patterns of carpal tunnel surgery by members of the American Society of Surgery of the Hand (ASSH) have recently been published. The majority of cases in this study were performed in the general operating room with intravenous (IV) sedation or a Bier block. Patients were most commonly prescribed hydrocodone for postoperative pain. The majority of carpal tunnel releases at our center are performed under local anesthesia alone, with plain acetaminophen (Tylenol) or codeine prescribed for postoperative pain. The authors were interested in determining whether these differences were specific to our center or whether there were nationwide differences among the Canadian Society of Plastic Surgery (CSPS) members compared to the ASSH members. We aimed to conduct a similar study to assess current trends across members of the CSPS to assess similarities and differences compared with current practices by members of the ASSH. METHODS: A 10-question survey, modeled after a previously published study, was sent electronically to Canadian plastic surgeons (n = 400). A description and a link to the survey was sent via e-mail and data were anonymously submitted and analyzed using descriptive statistics. RESULTS: The online survey was completed by 183 surgeons (46%). The local procedure room is used by 161 (surgeons 88%), whereas 15 surgeons (8%) used the general operating room. Subcutaneous local anesthetic is used by 98 surgeons (54%), a median nerve block by 68 (7%), a full wrist block used by 6 (3%), local anesthesia with IV sedation used by 6 (3%), a Bier block used by 3 (2%), and a general anesthetic used by 1 (0.5%). After surgery, 70 surgeons (38%) prescribed codeine, 49 (27%) prescribed plain paracetamol, 24 (13%) prescribed nonsteroidal anti-inflammatories, 21 (12%) prescribed tramadol, and 21 (12%) prescribed a narcotic stronger than codeine. CONCLUSIONS: Compared with data obtained from ASSH members, differences in practice by Canadian plastic surgeons responding to this survey appear to be related to type of anesthetic used and postoperative analgesia provided. The majority of procedures in this study were performed in a local procedure room under local anesthetic alone and the majority of patients are discharged with codeine or paracetamol. CLINICAL RELEVANCE: This study draws comparisons between Canadian plastic surgeons and members of the ASSH with respect to carpal tunnel surgery and adherence to the American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Diagnosis and Treatment of Carpal Tunnel Syndrome.

Analgesic Consumption Following Outpatient Carpal Tunnel Release.

PURPOSE: Few studies have examined the consumption of prescribed opioid medications after elective outpatient surgery. A better understanding of opioid consumption after elective upper-extremity surgery may lead to improved prescribing practices, decreased costs, and less leftover medication available for potential misuse. The goal of this study was to evaluate pain control and quantify the amount of leftover pain medication after outpatient carpal tunnel release. METHODS: We performed a prospective study of patients scheduled for outpatient carpal tunnel surgery. All patients had failed nonsurgical treatment and had an electromyelogram/nerve conduction study confirming the clinical diagnosis. All patients were encouraged to remove the dressing on the first postoperative day. A total of 56 patients were initially enrolled in the study; 7 did not meet the inclusion criteria, which left 49 patients who completed the study. Average age was 57 years; 66% of patients were female. Information collected included analgesic prescribed, number of tablets consumed, and number of tablets remaining. Use of postoperative orthoses, complications, use of other analgesic medications, and reasons for not taking the prescribed analgesics were recorded. RESULTS: Paracetamol with codeine and paracetamol with tramadol accounted for all prescriptions. Patients most frequently were given a prescription for 40 tablets. Average number of tablets consumed was 10 (range, 0-40 tablets). More than half of patients consumed fewer than 2 tablets. The average number of postoperative days of analgesic consumption was 2 (range, 0-7 days). Overall 1,531 tablets were leftover from the entire cohort. CONCLUSIONS: This study demonstrates that excess prescription analgesics are being prescribed after carpal tunnel surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Use of Supinator Motor Branches in Targeted Muscle Reinnervation of the Superficial Radial Nerve.

Symptomatic neuromas of the superficial radial nerve (SRN) can cause debilitating pain. Traditional surgical management options have demonstrated inconsistent outcomes prompting a search for alternatives. Recent reports have emerged on the use of targeted muscle reinnervation (TMR) for neuromas of the SRN using donors that are well established in hand surgery, such as the brachioradialis (BR) or extensor capri radialis longus or brevis. Use of the brachioradialis or extensor capri radialis longus motor targets can require surgery at or above the level of the antecubital fossa, and denervation of these muscle groups may be undesirable in cases of complex upper extremity injury where these donors may be needed for tendon or nerve transfer. The supinator is an expendable and often overlooked donor nerve that has not been assessed as a target for TMR of the SRN. In this case series, three patients with SRN neuromas whose conservative management failed and who did not have an SRN lesion amenable to reconstruction were managed with TMR to the nerves to supinator. At latest follow-up (9-22 months), no patients had deficits in supination or evident donor site morbidity. Two patients reported complete resolution of their SRN neuroma pain, and one patient reported partial improvement. This case series reports early results of TMR of the SRN using nerves to supinator in cases of SRN neuromas not amenable to reconstruction, demonstrating technical feasibility, improvements in neuroma pain, and no discernible donor morbidity.

Gender-affirming Clitoroplasty and Construction of the Clitoro-urethral Complex: An Anatomy Guided Selection of Two Techniques.

OBJECTIVE: To present 2 clitoroplasty techniques-the preputial skin and urethral flap-and describe our rationale for using each technique to construct the clitoro-urethral complex in gender-affirming vaginoplasty. METHODS: For uncircumcised patients or circumcised patients with greater than 2 cm of inner preputial skin and at least 8 cm of shaft skin proximal to the circumcision scar, we use the preputial skin clitoroplasty, a modification of the Ghent style clitoroplasty. The entire corona is used after medial glans and urethral mucosa is excised. The corona is brought together 1 cm from midline to create the visible ovoid clitoris; the remaining coronal tissue remains lateral to the clitoris for erogenous sensation as clitoral corpora. The clitoris is anchored to the proximal tunica, positioned at the level of the adductor longus tendon. The folded neurovascular bundle is fixed in the suprapubic area. The ventral urethral is spatulated and urethral flap approximated to the clitoris. Preputial skin is sutured proximally as tension allows. The clitoro-urethral complex is inset into an opening created in the penile skin flap. For patients with less skin, we use the urethral flap clitoroplasty. More corpus spongiosum is used, as the urethra creates the clitoral hood; this is described in the literature and attributed to Pierre Brassard. The clitoris is inset following a dorsal urethrotomy, with a small collar of preputial skin sewn to the spongiosum and urethral mucosa. The urethra is transected about 1 cm distally. The ventral urethra is then spatulated and the urethroplasty completed. RESULTS: We prefer the preputial skin flap technique for its' greater coronal tissue volume for erogenous sensation and better esthetics, in our opinion. Circumcised patients should have at least 2 cm of skin distal to the circumcision scar. To avoid using skin graft for the introitus-a risk for introital stenosis-shaft skin proximal to the circumcision line should be at least 8 cm. CONCLUSION: We present 2 technical options for clitoroplasty and construction of the clitoro-urethral complex in gender-affirming vaginoplasty.

Tissue Options for Construction of the Neovaginal Canal in Gender-Affirming Vaginoplasty.

Gender-affirming vaginoplasty (GAV) comprises the construction of a vulva and a neovaginal canal. Although technical nuances of vulvar construction vary between surgeons, vulvar construction is always performed using the homologous penile and scrotal tissues to construct the corresponding vulvar structures. Therefore, the main differentiating factor across gender-affirming vaginoplasty techniques is the tissue that is utilized to construct the neovaginal canal. These tissue types vary markedly in their availability, histology, and ease of harvest and have different advantages and disadvantages to their use as neovaginal lining. In this narrative review, the authors provide a comprehensive overview of the tissue types and associated operative approaches used for construction of the neovagina in GAV. Tissue choice is guided by several factors, such as histological similarity to natal vaginal mucosa, tissue availability, lubrication potential, additional donor site morbidity, and the specific goals of each patient. Skin is used to construct the neovagina in most cases with a combination of pedicled penile skin flaps and scrotal and extra-genital skin grafts. However, skin alternatives such as peritoneum and intestine are increasing in use. Peritoneum and intestine are emerging as options for primary vaginoplasty in cases of limited genital skin or revision vaginoplasty procedures. The increasing number of gender-affirming vaginoplasty procedures performed and the changing patient demographics from factors such as pubertal suppression have resulted in rapidly evolving indications for the use of these differing vaginoplasty techniques. This review sheds light on the use of less frequently utilized tissue types described for construction of the neovaginal canal, including mucosal tissues such as urethral and buccal mucosa, the tunica vaginalis, and dermal matrix allografts and xenografts. Although the body of evidence for each vaginoplasty technique is growing, there is a need for large prospective comparison studies of outcomes between these techniques and the tissue types used to line the neovaginal canal to better define indications and limitations.

Optimizing aesthetics in gender-affirming vaginoplasty and vulvoplasty: a narrative review and discussion based on over 600 cases of transfeminine vulvar construction.

Background and Objective: The vulva is the external portion of a gender-affirming vaginoplasty or vulvoplasty procedure-the "visible" result of surgery. The vulvar appearance can play a major role in how individuals feel about their surgical results and new genital anatomy. Therefore, optimizing the aesthetics of the vulva is an important component of surgical care. Although there is no one "ideal" vulvar appearance, aesthetics are optimal when each major sub-unit of the vulva is reconstructed to create a proportional and cohesive vulvar unit. In this article we perform a narrative review of the literature and discuss clinical approaches to improve aesthetic satisfaction such as patient education, re-defining the "ideal" vulva, aesthetic surgery tenets and technical strategies based on our collective experience of over 630 gender-affirming vulvar constructions. Methods: A narrative review of the literature was completed accessing PubMed, EMBASE, Google Scholar using search terms "Vaginoplasty OR Vulvoplasty". Articles were removed if not pertaining to gender affirmation surgery, were not in English language, were not accessible or did not discuss aesthetics in the body of the text. Key Content and Findings: A total of 1,042 articles were identified from initial search criteria. Of those, 905 were excluded as they did not involve gender affirmation as an indication. An additional 112 papers were excluded as they were not accessible, not in English, focused on non-vulvar outcomes or did not comment on vulvar aesthetics. Ultimately 25 articles were included for narrative review; 21 of these included technical descriptions of vulva and 13 had direct aesthetic discussion. The anatomy and aesthetics of the transfeminine vulva are reviewed according to the previously described principle of anatomic vulvar sub-units: the labia majora, labia minora, clitoris, urethra and the introitus. Conclusions: Ultimately, creating the optimal vulva for each individual patient will demand flexible surgical decisions based on individual anatomy and available tissues. This narrative review provides an overview of current approaches to aesthetics in gender-affirming vulvar construction and technical insights based on our institutional experience of performing over 630 gender-affirming vaginoplasty and vulvoplasty procedures.

Complications and management of excessive phallic turgor following gender-affirming phalloplasty.

Gender-affirming phalloplasty involves flap tubularization, placing unique stresses on the vascularity of the flap. Tubularization renders the flap susceptible to postoperative edema that can lead to excessive turgor that, if left untreated, can compromise perfusion and threaten the viability of the phallic reconstruction. This phenomenon has not been formally described in our literature. We aim to define this entity, described here as "Excessive Phallic Turgor" (EPT), and to outline its incidence, frequency of its underlying etiologies, and sequelae. We conducted a single-center, retrospective review of all phalloplasty operations involving flap transfer performed from December 2016 to May 2023. All patients requiring emergent intervention (bedside suture release, reoperation, or both) due to excessive phallic swelling and impending flap compromise were considered to have EPT. Variables compared between groups included underlying etiology (categorized as congestion, hematoma or swelling), patient demographics, flap type and size, management, length of stay, and postoperative outcomes. Over the study period, 147 phalloplasty operations involving flap transfer for shaft creation were performed. Of those, 15% developed EPT. Age, BMI, flap length, flap circumference, flap surface area, single vs multistage operation, flap tubularization (shaft-only vs tube-within-tube), and flap donor site were not significantly different between the cohort that developed EPT and that which did not. Development of EPT was associated with higher rates of phallic hematoma, surgical site infection, shaft fistula requiring repair, and longer inpatient stays. When EPT develops, prompt diagnosis and alleviation of intraphallic pressure are paramount for mitigating short- and long-term morbidity.

Fat Necrosis in Single Perforator Deep Inferior Epigastric Artery and Superficial Epigastric Artery Perforator Free Flaps: A Prospective Randomized Study.

Background: The deep inferior epigastric perforator (DIEP) flap is the standard of care in autologous breast reconstruction. The superficial inferior epigastric artery perforator flap (SIEA) is an alternative reconstructive option, with the compromise of less donor-site morbidity but variable perfusion to subscarpal fat zones. Fat necrosis is a known complication from marginal perfusion variability. Volumetric analysis of fat necrosis has not been performed between the two reconstructive options, nor has the amount of flap necrosis following radiation. Our objective was to compare rates and volume of fat necrosis between single-perforator DIEP and SIEA flap techniques. Methods: A single-center, blinded, prospective cohort study of patients randomized between SIEA and DIEP breast reconstruction was conducted over 2 years (June 2011-July 2013). Inclusion criteria were women undergoing immediate reconstruction following mastectomy. Randomization protocols were strictly followed. Fat necrosis volumetric analysis was determined by an ultrasound-trained attending surgeon at 12 months postoperatively. Patient demographics and adjuvant/neoadjuvant cancer treatment were analyzed. Statistical analyses included Mann-Whitney U tests, chi square, and/or Fisher exact tests. P values of 0.05 or less were considered significant. Results: Fat necrosis was detected in 11 of 46 flaps (23.9%), with a median area of 17.9 cm2. There was no significant difference in prevalence of fat necrosis between the two flap types (P = 0.19). Postoperative radiation did not increase the prevalence (P = 0.30) or extent (P = 0.92) of fat necrosis. Conclusion: Single-perforator DIEP and SIEA flaps have comparable rates of fat necrosis. Postoperative radiation did not result in increased prevalence or extent of fat necrosis.